Harris Pastides, PhD, MPH discusses the potential for a fourth COVID surge [Podcast]

AMA Update

Potential fourth surge and other COVID questions

Apr 13, 2021

In today’s COVID-19 Update, Harris Pastides, PhD, MPH, an epidemiologist and AMA trustee, discusses the recent uptick in COVID-19 cases and possible quick-response approaches to curb the spread. He also shares insights from his role on the North and South Carolina governors' task force for future pandemic preparedness and stresses the importance of getting shots into arms.

Learn more at the AMA COVID-19 resource center.

Speakers

• Harris Pastides, PhD, MPH, epidemiologist and president emeritus, University of South Carolina

Unger: Hello, this is the American Medical Association's COVID-19 Update. Today, we're exploring a potential fourth surge and other lingering COVID-19 questions. I'm joined today by Dr. Harris Pastides, an AMA trustee and president emeritus of the University of South Carolina. Dr. Pastides has also worked with national and international organizations, including the World Health Organization and the National Institutes of Health. He has a PhD in epidemiology, and is calling in from Charleston, South Carolina. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Pastides, thanks for joining us. It's good to see you back here. We've been seeing headlines about a potential fourth surge in the U.S. What's your take on the recent uptick in cases?

Dr. Pastides: Well, if you look, Todd, at the history of how epidemics or pandemics decline, there are always blips. In other words, the curve that we always look forward to so much is never a monotonic line that goes from peak to gone. There are always some peaks and valleys even. The question with this one, with the outbreak in states like Michigan, Pennsylvania, New York and Florida, is whether this is in fact only a blip or a sign of worse things to come. And I know we'll be talking about that.

Unger: When you look at that kind of trajectory in some of these states, where you're seeing Michigan for number of cases kind of doubling, can you help me out, how much of a cause for a concern in the kind of blip versus trend?

Dr. Pastides: Well, the tried and tested path of, let's say, the Centers for Disease Control when you had outbreaks of any kind really is to bring in your interventions where they're most needed. I think we've got a number of states now that are spiking and whether debating, whether these will go away on their own or whether we will see additional increases. We need to get the resources right to them. If this were, for example, a foodborne outbreak or this were another kind of infectious disease, hepatitis, you name it, we would be investing new and more resources to those communities. I think that's what we need to do, like public health firefighters going in. It's hard to imagine taking resources away from other communities so I'm not advocating that, but as new resources come in line, I think we need to concentrate them in those areas.

Unger: So, talk a little bit more about that. I like that public health firefighters kind of metaphor. When we see kind of increases like this, where like the ember kind of explodes into a full on fire, what is that kind of force that goes into a state and provides that level of intervention that you're talking?

Dr. Pastides: Surely, the part of the dilemma of course is that we are 50 states, and so you've got to cross boundaries, and in the United States, that's more difficult than it would be in almost any other country in the world. But with some specificity, what I would say is you need to bring in rapid testing and rapid vaccination teams with tents or use athletic stadia, for example, or other facilities, public parks and just start bringing in all the people from those arenas, from those locations, without really respect to their age or anything, because what you have there, and it could be meteorological. One has to wonder why the northern states right now and why Florida, and I think, frankly, there are different reasons. Florida is the place where most young people during the spring flock and other tourists flock because of the weather, and also because there are fewer restrictions and no mandates.

And so I think the reason for Florida being high, it has nothing to do with the reason for Michigan being high. But regardless of the reason, public health can squander and waste a lot of time wondering why. The real thing isn't to ask why right now, but it's to bring in vaccination teams and really bring in people, forgive me when I say this but, off the street if they're not vaccinated. Get everybody in those communities that are spiking, vaccinated by any of the three approved vaccines right now. Do it as quickly as possible.

Unger: Dr. Pastides, speaking of vaccines, we're kind of in a race right now between vaccines and variants. In your book, which is winning?

Dr. Pastides: Well, I think vaccines will win. I do think that variants are of concern, and I'm fairly confident, although I hate to predict anything in the realm of medicine or public health, that we will continue to need vaccines against COVID variants in the future. By the way, both Moderna and Pfizer have been shown to be effective for at least six months. I hope it will be longer than that, but we have good experience now for six months. J&J, we're not so sure, but we're hopeful about that one as well. And so variants will continue, Todd, and now there's information about a so-called double variant, which sounds scary, but this is the nature of viruses. They are among the most elemental forms of life that we know, barely above plant life. And just about the only thing they can do when we are winning a war against them is to mutate.

And a double mutation simply means that it's one more degree of freedom away from the original, whatever we call that original, Wuhan or whatever we call it, that happened in early 2020. We have to be concerned that eventually there will be a mutation that renders the vaccines that we've been taking ineffective, and we're nowhere near that now. So it's important to have our guard up, to be vigilant, but really these variants are fodder for scientists, for laboratory investigations. We need to continue putting shots in the arms of people. And Todd, while I'm at it, let me say that history will define whether the prioritization of the elderly and the infirm was the right way to proceed or not.

And this may sound provocative to our listeners, to our physicians, and other listeners. I think there is no doubt that front-line health care workers should have been at the very, very front of the queue when I think that's for obvious reasons, but when you go beyond that, had we taken a public health control perspective, we may in fact have vaccinated young people first, college kids, other young people. And the reason is not because they mean more to us, not at all, but because they are exactly the people who are least likely to follow the recommendations of the CDC and the NIH, and even their physicians. They want to congregate, they want to socialize. They want to have a spring break. They want to go to the beach with friends.

And so ironically, what we did is we immunized those who were most likely to remain behind closed doors, those who were most likely to adhere to the recommendations of masking and social distancing. And again I'll say with good cause because we're at high risk for a serious disease and death, but I do believe should there be a pandemic like this in the future, we do need to revisit the staging of who got their vaccines first, second, third and fourth, so that we could account both for the need to protect our patients and our fellow citizens on one hand, but also to stem the epidemic or the pandemic more quickly on the other.

Unger: It's interesting. This is one of those situations where we're just kind of learning across the course of this year on so many fronts, unlike other things that we know we're kind of more used to. This kind of retrospective look at our pandemic approach and vaccination approach, who does that and how does that happen so we get to a conclusion about what the right way is, or is that just really going to depend on what we're facing?

Dr. Pastides: Well, Shakespeare in "The Tempest" said, "The past is prologue." And in this case, we hope not. And the only way to prevent that is to begin now documenting, analyzing, assessing and reviewing, without great sense of fear and panic. Politicians generally don't like to be assessed in that way, but we do need to do that. I happen to be privileged to be co-chairing a task force for North and South Carolina for the two governors. Together, we are starting a review of how these states could be better prepared in the future. And you can be assured these are the kinds of things we'll be looking at. I think we need that at the federal level too. How to do that, to try to be a little more devoid of politics than would generally be expected, I'm not sure. I hope the AMA could have a role in that, but we better start doing it before too long lest we forget both from mistakes but also the wonderful contributions and decisions we've taken to date.

Unger: Well, a little bit closer in and kind of back to the increases that we're seeing right now, some public health experts indicate that we have the tools to stop the increases that we're seeing, but that we need to act quickly. We've been hearing terms like "ring vaccination" to help control those clusters. What do you think about a strategy like that?

Dr. Pastides: Well, great idea. Let me take us back to the only infectious disease that was eradicated in our lifetimes, maybe not in yours, Todd, being so young, but smallpox. And I can assure you that smallpox would still be with us if we had not taken that ring approach. And so when there were cases remaining on the planet, the WHO and its partners would go into those communities, by the way, very remote often places with displaced individuals or war-torn, impoverished largely, and they would basically create a ring and made sure that 100% of the people within that ring were vaccinated with the smallpox vaccine. And eventually, that was the only way to stem it. Now, smallpox being a much more deadly virus than COVID, I don't mean to draw them together in the same way, but I do think right now we ought to be thinking about a ring approach. It may be a tad too early because if the spikes are distributed very widely, let's say throughout Michigan, very difficult to have a ring around Michigan. But if you have ...

Unger: It's a very big ring.

Dr. Pastides: ... pockets ... A very big ring, too big a ring, not possible to ring Michigan, but if we have pockets of where the virus and the disease is spiking in a community, be it urban or rural, by bringing in mobile medical units, doing a lot of testing but especially getting the vaccine out, this is a time for just putting the vaccine in the arms of people. And I would redeploy resources, whether it's a ring approach or some other from within approach to get those communities vaccinated right now. I'm talking right now, this weekend, this upcoming weekend, next week. Or, the ring will not hold, the people will travel, visiting family, and then you'll see these spikes continuing. I'm very optimistic, Todd. This pandemic is going away, but is it going to go away as the president indicated? "Hopefully, we can all have a fun July 4th weekend," he said recently. Or will it be much later than that, will really depend on these continued spikes and how well we, the public health and medical community, do at intervening with them sooner rather than later.

Unger: It's very interesting what you're saying because I think right now in the phase that we're in with vaccinations, it's kind of a state-by-state thing, but you're saying as we see kind of these flare ups, it's almost like a vaccine SWAT team to move in and employ this kind of ring strategy to stop that in its tracks. So, it's kind of a cross-state prioritization there that I haven't seen that happened yet.

Dr. Pastides: And by the way, it is exactly that. I might take exception to the word ring only because that implies a circular type thing. It's often not a ring, but it is a focus approach. The CDC, they are expert, I'll go as far as saying they are the world's experts in that activity. And if they were to be asked or supported to do that, they could send team members to these affected areas and recruit other medical personnel volunteers, and they could do an amazing job. This is what they do every single day. They have not done it with COVID, but they've done it with many, many other diseases, and they do know how to do that and do it well and do it quickly.

Unger: What indicators should physicians be looking for right now to get an accurate picture of what's happening in their own communities so that we can be on guard to prevent something like this from happening in other places?

Dr. Pastides: Well, two good places I think. First of all, the Johns Hopkins University has a website that will tell you at a more macro level how communities are doing. And I don't know that you could get down to the census tract or zip code, but you can get fairly narrow with that. That's a good place to start, but maybe even better would be to look at the CDC reports relative to vaccination rates. And if you're a practitioner in a community where for whatever reason the vaccine behavior has not been what we all hope it would be, you ought to be alarmed and concerned that you'll continue to be seeing positive COVID tests and all of the attendant pressures on hospitalization, and emergency rooms and respirator needs, and all of that. And so I think if I were a practitioner, that's what I would be trying, I would look at the vaccination rate as close to my community as I could find it, and make that be the predictor of what I'm going to be seeing in practice at least for the foreseeable future.

Unger: You wrote an article very early on in the pandemic entitled, "How to reopen America." And in that, you advocated for widespread testing, particularly antibody testing as a tool for phase reopening. It's something we had never really saw necessarily happen. Does antibody testing still have a big place in our response, or vaccines has changed that?

Dr. Pastides: They have changed it. I think at the time that was the right thing to do. Todd, many people, we've just forgotten our basic virology 101, which basically says if you've gotten the disease, you really very, very, very unlikely to get it again at least anytime soon. And number two, if you've been vaccinated by a good vaccine, you are very, very, very, very unlikely to get it at least anytime soon, until there are new strains maybe. So we need to worry less about who's had it, we need to worry about who's not vaccinated. Antibody testing, unfortunately, it's a blood test. It's not as simple as doing a COVID test. And we really haven't done the large scale national studies that look at antibodies to see how well protected people are. Plenty of anecdotal evidence that they're well protected, but there are a whole lot of people who had mild cases back in April who may or may not be as well-vaccinated as those of us listening today who've been fully vaccinated.

And so, yeah, I think antibody testing still has a role. And certainly, in research, it does. Who have what strains, but I think that's kind of tomorrow. Let's take care of our people today and let's get them the shot in the arm. And although there is some evidence of a very, very few people who have been vaccinated and appear to have gotten COVID, I want our listeners to know the numbers are extraordinarily low. We are talking about less than a part of a part of a percentage point with well over a hundred million Americans having been vaccinated. There is some evidence that maybe a hundred or so. You can do the math as well as me. That is not unimportant to those people, but negligible. We have the answer, we have the fire hose, we just need to distribute it to people, especially young people.

Let me just repeat. Now is the time to get shots in the arms. Several universities like Rutgers and Cornell have already announced that no student will be returning to campus in the fall without proof of vaccination. That's I think the way most colleges will go in the fall. There's also debate about a vaccine, call it what you will, passport. And I know that many Americans don't like that idea. They don't like their privacy invaded and they don't like restrictions on them, but I can assure you those of us who plan to be going to Europe, for example, some countries in Europe, later this summer, in the fall will need that vaccine passport, will need to show. And that's something... I'm not making a political statement about a vaccine passport for the U.S. other than to say this is going to become more and more standardized within the U.S. If the government won't do it, universities will do it. Places of employment will do it. And I think we will grow more comfortable with that over time.

Unger: We're fortunate that the pace of vaccinations has accelerated so dramatically here in the U.S. but we're seeing varying rates of that, of course, globally. And back to the article that you wrote about reopening, you called for vaccine production to gear up worldwide simultaneously, saying, "Nothing would be worse than an international food fight about access to the vaccine, especially among the haves and the have-nots." Is that what we're seeing right now? And if so, what's got to happen to change that?

Dr. Pastides: Well it's too late to change it fundamentally, to having to change the supply chain for Europe. That's not something you or I could do anything about. I think when they do their review, they need to look at what didn't work properly there. I would also say though that generally in Europe have had and have more compliant populations relative to lockdowns. Not everywhere, the Italians are up in arms right now. But by and large, they were more compliant than Americans were, by and large, to restrictions. Yeah, America is just about to have a glut, and that is a good thing, but how we deploy it ... Do you go with our neighbors to the north and south? Do you offer to Mexico and Canada first, as an example?

I believe we need to offer vaccines to international students. And that's my field, higher education. International students who are planning to come to the U.S. for the fall, I think we should supply the vaccine to those individuals, because we want them here but we need them to be healthy as well. But beyond that, what countries do we help and what order? I do believe by the way though that hoarding or warehousing millions of vaccines is not a good idea for the United States mainly because I believe should there be a need for continuing vaccination later in 2021 or in 2022, those vaccines are probably not the ones we would be taking. Same platform, but different concoction or formulary.

And so I think to save those at great logistical expense and the freezer, refrigeration needs, to have them around when there are people around the world who will maintain the pandemic in spite of Americans largely having been vaccinated is not a great idea, but it's not in my realm to recommend how they be deployed. But I think it's a good time to begin thinking about how they would be shared with other people in other countries.

Unger: Well, thank you so much, Dr. Pastides. Your comments are so thoughtful and I really, really appreciate your perspective and being here today. That's it for today's COVID-19 Update. We'll be back with another segment shortly. In the meantime, for resources on COVID-19, visit ama-assn.org/COVID-19. Thanks for joining us. Please take care.

Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.